RxAssist Home
RxAssist Home Home  |  About Us  |  Contact RxAssist          
      Patient Assistance Program Center
 
 

Program Details

TG THERAPEUTICS
BRIUMVI Patient Support

BRIUMVI (ublituximab-xiiy)
 
CONTACT INFO
Address: PO Box 2355
Morristown, NJ 07962
Phone: 1-833-274-8684 Provider Phone:
Fax: Website: Program Website
ELIGIBILITY
Eligibility Info:
  • Contact program for details.
  • Patient must be a permanent US resident
  • Income guidelines are based on fixed annual gross household income per household size. See guidelines below.
  • Income at or below: Single 100,000 % FPL
      Couple 150,000 % FPL
    Federal Poverty Level Calculator Federal Poverty Level Calculator
    Other Income Requirements: $25k for each additional household member
    Medical expenses can be deducted from reported income: No
    Social security requested on form: No
    US citizenship/residency specified: Yes
    APPLICATION
    Attachments Required: Patient Consent Form
    Physician License #
    Required:
    State
    Prescriber Signature
    Allowed:
    Physician
    Application may be
    faxed:
    Yes
    Eligibility determination
    letter sent:
    Not Published
    MEDICATION
    Receives: Pharmacy Card
    Shipped To: Provider
    Quantity in Shipment: Not Published
    Delivery Time: Not Published
    Re-application Policy: Not Published
    Refill Policy: Not Published
    Other Information:

    Last Updated: 02/01/2023

     

     

     


    Application Forms
    & Instructions

    The following documents are provided in interactive PDF format, allowing you to type information directly into the form.



     

    Print-friendly version

    This information is for informational purposes only and is not meant to be a substitute for professional medical advice, diagnosis or treatment. Neither RxAssist nor RxVantage is offering advice, recommending or endorsing any specific prescription drug, pharmacy or other information on the site. Neither RxVantage nor RxAssist provide any warranty for any of the pricing data or other information. Please seek medical advice before starting, changing or terminating any medical treatment. Third party logos, trademarks, brand names and images contained on rxassist.org or rxvantage.com are for demonstration purposes only and are owned by their respective rights holders, who are not affiliated with this Site.

    Copyright © 2024, RxVantage, all rights reserved.